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Med – Rheumatology Exam (Actual Exam)
- Which of the following clinical manifestations is most characteristic of polymyalgia rheumatica (PMR)? (A) subcutaneous inflammatory lesions (B) pain and stiffness of proximal muscle groups (C) insidious onset of symmetrical joint involvement (D) widespread musculoskeletal pain and tender points (E) symmetrical weakness initially in the legs that progresses caudally - Answer -(B) pain and stiffness of proximal muscle groups An abrupt onset of proximal muscle pain and stiffness in the shoulder and pelvic girdle areas, usually associated with fever, malaise, and weight loss, is characteristic of polymyalgia rheumatica.
- A 53-year-old obese man presents with a third attack of gout within 1 year. Following the treatment of this acute attack, further laboratory testing is performed and the patient is found to have an elevated serum uric acid level and a 24-hour uric acid secretion of 950 mg. Which of the following medications would be most appropriate to initiate for prevention of further gouty attacks? (A) colchicine (B) probenecid (C) prednisone (D) allopurinol (E) indomethacin - Answer -(D) allopurinol
Medications used to prevent gout exacerbations include allopurinol and uricosuric drugs, such as probenecid. Allopurinol inhibits the production of uric acid and is indicated for patients who overproduce uric acid, and uricosuric drugs are used in patients who under-secrete uric acid. Criterion to classify a patient as an overproducer of uric acid is a 24-hour uric acid excretion test. The result showing uric acid excretion of 800 mg or greater indicates that the patient is an overproducer. In this patient scenario, there is an overproduction of uric acid, making the case for the use of allopurinol. If this patient's 24-hour uric acid excretion was less than 800 mg, the use of a uricosuric drug would then be appropriate. Prednisone, colchicine, and indomethacin are alternative treatments for acute attacks of gout and are not used for preventive measures.
- A 32-year-old woman with history of anxiety presents with worsening fatigue and sleep disturbance associated with unbearable "pain all over the body" for the past several months. The physical examination is essentially unremarkable except for localized painful tenderness to palpation over the trapezius, upper back, and buttocks. Which of the following is the most likely diagnosis? (A) fibromyalgia (B) polymyositis (C) Paget disease (D) polymyalgia rheumatica (E) systemic lupus erythematosus - Answer -(A) fibromyalgia
(E) eosinophilia-myalgia syndrome - Answer -(B) Scleroderma is characterized by diffuse thickening of the skin and is associated with areas of telangiectasia and changes in skin pigmentation. Most patients with scleroderma also have an associated polyarthralgia, Raynaud phenomena, and gastrointestinal involvement.
- Which of the following conditions is strongly associated with systemic sclerosis (scleroderma)? (A) polymyositis (B) reactive arthritis (C) dermatomyositis (D) Sjögren disease (E) Raynaud phenomenon - Answer -(E) Raynaud phenomenon Most patients with systemic sclerosis (scleroderma) will also have vascular dysfunction, most commonly Raynaud phenomenon. There is no increased association of scleroderma with polymyositis, reactive arthritis, dermatomyositis, or Sjögren disease.
- A 65-year-old man presents with complaints of acute onset of pain and swelling of the right great toe. He denies recent alcohol ingestion or trauma to the area. On physical examination, the patient is afebrile, and the first metatarsophalangeal joint is erythematous, swollen, and warm to the touch. Laboratory evaluation reveals a WBC (white blood cells) count of 12,000/μL and a normal differential. Serum uric acid level is found to be 5 mg/dL. Synovial fluid analysis reveals the presence of rhomboid-shaped crystals. Which of the following is the most likely diagnosis?
(A) acute gout (B) pseudogout (C) psoriatic arthritis (D) infectious arthritis (E) rheumatoid arthritis - Answer -(B) Pseudogout presents similarly to acute gout and is best diagnosed by the finding of the rhomboid-shaped crystals of calcium pyrophosphate in joint aspirates.
- Which of the following patterns of stiffness is most characteristic of patients with rheumatoid arthritis? (A) morning stiffness lasting at least 1 hour (B) exacerbation of joint stiffness with walking (C) frequent, brief episodes of stiffness after inactivity (D) stiffness reflected by a major delay in muscle relaxation (E) stiffness evidenced by increased resistance to passive movement - Answer -(A) morning stiffness lasting at least 1 hour
- Related infections that have been identified as triggers of reactive arthritis include sexually transmitted infections and which of the following other types of infections? (A) ear infections (B) eye infections (C) enteric infections (D) musculoskeletal infections (E) central nervous system infections - Answer -(C) Reactive arthritis, previously known as Reiter syndrome, typically presents with the clinical triad of urethritis, conjunctivitis, and arthritis. Most cases of reactive arthritis are associated with either a sexually transmitted infection (STI) or an enteric infection. Common STI etiological
(D) immunoglobulin (E) hydrochloroquine - Answer -(A) prednisone The most likely diagnosis in this patient is polymyositis. This is supported by the finding of a gradual progressive proximal muscle weakness and elevation of creatinine phosphokinase level. The finding of lymphoid inflammatory infiltrates on muscle biopsy confirms the diagnosis. Initial treatment of choice in this condition is the use of a corticosteroid (prednisone). Patients who do not respond to prednisone may then benefit from the use of methotrexate or azathioprine. Both intravenous immune globulin and hydroxychloroquine are effective for the treatment of patients with dermatomyositis that is resistant to prednisone therapy. (
- Which of the following is the correct term to describe the abrupt onset of swelling and extreme tenderness to palpation involving the metatarsophalangeal joint of the great toe? (A) crepitus (B) podagra (C) xerostomia (D) trigger point (E) chondrocalcinosis - Answer -(B) podagra
- A 22-year-old man presents with an insidious onset of low back pain over the last 6 months. He describes the pain as dull and has difficulty localizing the pain. The pain often radiates to his thighs. The pain is worse in the morning and associated with stiffening that lessens during the day. The patient notes that there is no history of trauma. The initial laboratory evaluation shows
an elevated erythrocyte sedimentation rate, positive HLA-B27, and a negative rheumatoid factor. Plain films of the lumbar spine reveal bilateral blurring of the sacroiliac joints. Which of the following is the most likely diagnosis? (A) systemic lupus (B) lumbar disc disease (C) rheumatoid arthritis (D) ankylosing spondylitis (E) polymyalgia rheumatica - Answer -(D) ankylosing spondylitis
- A 65-year-old woman with long-standing rheumatoid arthritis presents for a preoperative evaluation appointment. She is scheduled for a total joint arthroplasty in 2 weeks. Which of the following is the most appropriate intervention to detect an associated condition that may lead to complications during anesthesia? (A) HLA (human leukocyte antigen) typing (B) slit-lamp examination (C) thorascopic lung biopsy (D) repeat rheumatoid factor (E) flexion and extension x-rays of cervical spine - Answer -(E) flexion and extension x-rays of cervical spine
- Which of the following clinical manifestations is associated with systemic disorders that are HLA-B27 related, including ankylosing spondylitis, reactive arthritis, psoriasis, and Behçet syndrome? (A) uveitis (B) dysentery (C) vasculitis (D) hyperuricemia (E) thoracic involvement - Answer -(A) uveitis
most likely have more serious and seropositive RA disease.
- Reactive arthritis most commonly presents with a tetrad of urethritis, conjunctivitis, mucocutaneous lesions, and oligoarthritis. Which of the following joints are most commonly involved with this condition? (A) sacroiliac joints (B) metatarsophalangeal joints (C) large weight-bearing joints (D) metacarpophalangeal joints (E) distal interphalangeal joints - Answer -(C) The most common joints involved in reactive arthritis are the large weight-bearing joints of the knees and ankles.
- Which of the following medications has been shown to have a definite association with the potential development of systemic lupus erythematosus? (A) isoniazid (B) penicillin (C) gold salts (D) allopurinol (E) griseofulvin - Answer -(A) isoniazid
- A 52-year-old man with hypertension associated with recent unexplained weight loss presents with fever, malaise, and gradual onset of pain and weakness of his leg muscles for the past month. Physical examination reveals a mottled reticular pattern overlying portions of both calves and an area of ulceration with surrounding induration on the left lateral malleolus. Initial laboratory results reveal mild normochromic anemia, leukocytosis, and elevation of C-reactive
protein, BUN, and creatinine. Which of the following is the most appropriate diagnostic evaluation to confirm the suspected diagnosis? (A) HLA-B27 typing (B) rheumatoid factor (C) MRI of sacroiliac joints (D) antinuclear antibodies test (E) tissue biopsy of area of induration - Answer -(E) This patient most likely has polyarteritis nodosa (PN). A major obstacle in making the diagnosis is the absence of a disease-specific serological test. The diagnosis requires confirmation with either a tissue biopsy or angiogram. Patients diagnosed with Sjögren syndrome should be counseled to avoid which of the following class of medications? (A) penicillins (B) decongestants (C) antihistamines (D) corticosteroids (E) fluoroquinolones - Answer -(B) Sjögren syndrome is an autoimmune disorder that commonly presents with dryness of the eyes, mouth, and other areas of the body covered by mucous membrane. Because of the chronic dysfunction of the exocrine glands and chronicity of dryness of the eyes and the mouth, patients should be counseled to avoid decongestants and atropinic drugs. The use of these medications can further exacerbate their symptoms. What is the only known environmental factor known to cause a flare of SLE? - Answer -sunlight (UVB light)
What chronic inflammatory condition occurs with > 60 minutes of morning stiffness? - Answer -RA What is the goal of tx for RA? - Answer -Avoid disability providing earlier treatment What is the most common risk factor causing RA? - Answer - smoking Which population is most affected by RA? - Answer -Females 20- 40s What are the 2 major phases of RA? - Answer --Lymph node phase -Joint phase What leads to destruction of bone and cartilage which manifests as joint space narrowing and bone erosions in RA? - Answer - Pannus What are the early signs of RA? - Answer --Fatigue -AM joint stiffness due to fluid accumulation What are the symptoms that can occur after weeks to months of being dx with RA? - Answer --Joint deformity -Joint pain from swelling and inflammation What are the symptoms that can occur after months to years of being dx with RA? - Answer --Extra-articular involvement -Gradual functional impairment What joints are affected with RA? - Answer --Small joint of hands and feet -PIP, MCP,wrist, elbows, shoulders, cervical spine -Hips, knee, ankle MTP
Why is it important to do an x-ray in a pt who has RA prior to receiving anesthesia? - Answer --B/c RA affects cervical spine there is more susceptibility self decapitation do fragile state of the bones What do you order for an RA pt prior to receiving anesthesia? - Answer -x-ray Is RA symmetric or asymmetric? - Answer -Symmetric Is RA polyarticular, mono articular, or oligoarticular? - Answer - Polyarticular What joints are spared with RA? - Answer --DIP What are the signs on PE in RA? - Answer --Joint swelling -Purplish tint over the joints -Warmth -Decreased ROM -Pain ROM -Joint deformity What is fusiform swelling and what condition is it associated with?
- Answer --Soft-tissue swelling is an early finding in rheumatoid arthritis and usually appears as typical fusiform or spindle-shaped enlargement of the proximal interphalangeal joints. The second and third fingers of this patient are most involved. -RA According to the american college of rheumatology, what is the score needed to have a definite dx of RA? - Answer -6 or higher What other 2 criteria are needed to have a definite dx of RA? - Answer --presence of synovitis in at least one joint
What is the triad of Felty's syndrome? - Answer --RA -Splenomegaly -Leukopenia What is rheumatoid vasculitis? - Answer --Serious vasculitis -Usually in men w/ severe RA -life threatening complication What are the 3 tendon related diseases that can occur with RA? - Answer --Tendonitis -Tendon rupture -Carpal tunnel syndrome Is RA or OA associated with Upper Cervical Spine dz? - Answer -- RA What are the laboratory test done in pt with RA? - Answer --CBC (anemia-normocytic) -ESR (increased) -CRP (increased) What organs are crucial to check when prescribing medication to an RA pt? - Answer --Renal function (BUN, Creatinine, UA) -Liver function (ALT, AST, ALP, ALB, Hep B & C, Ab/Ag testing) What type of x-ray should be done as a baseline prior to prescribing meds in an RA pt? - Answer --chest x-ray What are the antibodies present RA? - Answer --Rheumatoid factor -Anti-nuclear antibody -Anti-CCP
Which test is not a specific test for RA? - Answer --Rheumatoid factor (not present early in dz, but high sensitivity, useful to confirm a clinical impression) What dz is important to think about with a positive RF in a pt with RA? - Answer --hepatitis C Is RA a migratory or non-migratory dz? - Answer --Migratory In confirmed RA pt, what antibody is going to tell you if RA has a more aggressive dz course? - Answer --Rheumatoid factors What antibody test is NOT useful for the diagnosis of RA? - Answer --Rheumatoid factor T or F: Asymptomatic people with a positive RF unlikely to go on to develop RA - Answer -TRUE T or F: The higher the value of RF the greater the likelihood of rheumatic dz - Answer -TRUE T or F: Rheumatoid factor is useful for prognosis of RA - Answer - TRUE What antibody has a HIGH specificity for RA? - Answer --Anti- CCP Can pt 's who are anti-CCP positive be seronegative for RF? - Answer --yes What antibody is rarely associated with Hep C in RA? - Answer -- Anti-CCP What is the goal of treatment with RA? - Answer --Control the dz early on
How often can you give corticosteroid injections? - Answer --3 to 4 times in the same joint per year What are side effects of corticosteroid injections? - Answer -- Infection -Tendon weakening -Irreversible depigmentation of dark skin What class of medication has been shown to reduce radiographic progression? - Answer --DMARDs What are the 2 benefits of DMARDs use? - Answer --Improve pain -improve function T or F: All patients with RA should be taking a DMARD - Answer - TRUE When should DMARDs be started after dx a pt wth RA? - Answer --within 3 months How do you treat mildly active RA? - Answer --NSAID (or Tylenol)
- DMARD (Methotrexate, Hydroxychloroquine or Sulfasalazine) How do you treat moderate to severe RA? - Answer -- DMARD(Methotrexate, Hydroxychloroquine or Sulfasalazine) + NSAID or Glucocorticoid (or Tylenol) If a patient is resistant to initial DMARD what are your options? - Answer --Combination of different DMARDs (MTX + TNF inhibitor or SSZ and HCQ) -Switching to a biologic (Infliximab)
How long can it take for a DMARD to achieve full benefits? - Answer --3 to 6 months What are examples of DMARDS? - Answer --Methotrexate -Leflunomide -Sulfasalazine -Plaquenil (Hydroxycholoroquine) Can biologics be used in combination with DMARDs? - Answer -- yes How are DMARDS given? - Answer --Orally How are biologics given? - Answer --Subcutaneous Injections or IV infusions Should a pt with RA who is currently taking biologics take a live vaccine or not? - Answer -No live vaccines while taking biologic medications Who are biologic medications NOT recommended for? - Answer --Ppl with MS -Pt with CHF -pregnant women What supplement must a pt taking methotrexate take daily? - Answer --Folic acid When are biologics stopped in a RA pt who is about to have surgery? - Answer --1 week before surgery -start 1 week after surgery (according to pt status) What are examples of biologics? - Answer --Etanercept -Infliximab -Anakinra
